Provider Demographics
NPI:1457457251
Name:NOVAK, SANDRA L (PSYD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355TH MDG/OMRS - MENTAL HEALTH CLINIC
Mailing Address - Street 2:5427 E MADERA ST, BLDG 4339
Mailing Address - City:DAVIS-MONTHAN AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-4357
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-859-7579
Practice Address - Fax:623-856-4433
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008889103TC0700X
AZPSY-005303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400210383OtherMEDICARE PTAN